Smile line and marionette filler gone wrong, and only offered surgery? Get assessed first

Smile line filler gone wrong, and only offered surgery? Read this first

Patients come to Dr Sin Yong after being told that filler in their smile lines or marionette lines has to be cut out, that a face-lift is the way to take the weight off, or that nothing can be done. Before you agree to an operation, know what it means:

• A scar. Every cut through the skin of the face heals with a scar.
• A dent. Cutting out a lump takes tissue with it, and the area can heal hollow or uneven.
• Nerve injury. Nerves that give the face feeling and movement run close to where filler sits. An injured nerve can leave numbness, or weakness in a smile, a lip or a brow.
• Product left behind. Filler spread through tissue is hard to remove completely.
• No way back. Tissue that has been cut out cannot be put back.

Removal through the inside of the mouth avoids a scar on the skin, but it still cuts through the tissue around the filler, with the same risks of a dent, nerve injury and product left behind. A face-lift repositions skin and deeper tissue through incisions around the ears; on its own, it does not take the filler out.

Dr Sin Yong maps the folds with ultrasound, dissolves hyaluronic acid, and treats material that cannot be dissolved, silicone included, with the Sculpting mode of Time Freeze Laser LCLR®, without an incision. In Dr Sin Yong's practice, almost every hard lump is treated without surgery. If yours is one of the few that needs surgery, you are told plainly, and why.

Why filling the folds can leave a heavy, pillowy or droopy lower face

The smile line, or nasolabial fold, runs from the side of the nose to the corner of the mouth. The marionette line runs down from the mouth corner towards the jaw. Both sit where the mobile cheek and jowl meet the firmer tissue around the mouth. With age, much of their deepening comes from tissue moving down from above, not from volume missing in the fold itself. Filler placed into the fold adds weight exactly where tissue is already gathering.

Filler also stays, and it builds up. In a 3D MRI study of 14 patients with documented injection histories, filler volumes on MRI were about 2.8 times the volumes injected, in regions that included the nasolabial area (Issa 2026). Facial overfilled syndrome, which includes the pillow face, comes from too much filler and filler placed in a way that does not suit the anatomy, and it is reported mainly in people of East Asian descent (Lim 2024).

What it looks like

• A heavy, flat or sausage-shaped ridge beside the nose or the mouth.
• Cheeks and smile lines that merge into one soft block, so the face looks fuller and wider than it did.
• A bulge that moves up as a block when you smile.
• Mouth corners that look pulled down, and a lower face that looks tired or sad.
• Lumps, or a firm band, that you can feel along the fold.

A droopy mouth after marionette filler

A mouth corner that turns down after marionette filler is often the weight of product sitting low beside the chin, or product that has moved down towards the jawline. A droop that began within days of wrinkle-relaxing injections around the mouth is assessed differently: that points to a muscle effect from the injections, and dissolving filler does not change it. Pain that is getting worse, or skin that turns pale, dusky or mottled, is urgent; the warning signs are set out further down this page.

“For hard lumps from mixed products, I use one tool, Time Freeze Laser LCLR®, to target the material without surgery.”

Dr Sin YongOn hard lumps from mixed fillers and skin boosters

Lumps in the smile lines after filler

Most lumps in the folds are product that has gathered in one place or sits too close to the surface. Some are the body's reaction to the product, and these can appear long after the injection.

Hyaluronic acid

In an ultrasound study of 52 non-vascular complications of hyaluronic acid filler, the nasolabial area was the second commonest site (22%), after the under-eye area (23%). Across all sites, the commonest problems were the Tyndall effect, a bluish tint from filler sitting too close to the surface (25%), changes in the gel itself (21%) and foreign-body granulomas (15%), with migration and overcorrection also seen (Gonzalez 2024).

Lumps that flare after dental work or illness

Late-onset reactions to hyaluronic acid filler typically appear 3 to 4 months after injection. Proposed causes include the structure of the filler, infection, and an immune imbalance such as a viral illness or autoimmune disease, and recent dental treatment is one of the listed risk factors (Baranska-Rybak 2024), which matters in an area this close to the mouth. With non-absorbable fillers, symptoms began after dental procedures, more filler injections or other invasive facial treatments in 28% of 85 patients with delayed problems (Kadouch 2013).

Collagen stimulators

Calcium hydroxylapatite, poly-L-lactic acid and polycaprolactone are placed in the folds too. In a series of 55 complications after collagen stimulators, nodules made up 89% and usually appeared more than a month after treatment. Only five resolved completely despite a range of treatments, and hyaluronidase helped only where calcium hydroxylapatite had been combined with hyaluronic acid (Ianhez 2024).

Silicone and other non-absorbable fillers

Silicone, polyacrylamide gel, polyalkylimide and PMMA are found in the folds after older or overseas treatments. In a five-year study of PMMA in collagen injected into the nasolabial folds, a biopsy-confirmed granuloma developed in 1.7% of subjects; almost all responded to treatment, and 0.9% still had one at the end of the study (Cohen 2015).

Whatever the product, Dr Sin Yong maps each lump with ultrasound before anything is done. Lumps from every type of filler and skin booster are covered in hard lumps after filler or skin boosters.

Filler that has moved out of the folds

Filler does not always stay in the fold. It can spread up into the cheek, out towards the mouth corner or down towards the jaw, and a fold that looks wider or lower than before can be old filler that has moved rather than new ageing. Migration was among the problems seen in the ultrasound study of hyaluronic acid complications above (Gonzalez 2024). With older gels the problem can be larger: after polyalkylimide gel was placed in the cheeks, nasolabial folds or tear troughs, all four patients in one series had delayed complications, among them infection, migration of the filler, recurrent swelling and inflammatory nodules (Ross 2009).

Signs include fullness above the upper lip, a bulge beside the mouth that appears when you smile, and a firm band running down towards the jaw. Ultrasound shows where the product sits now, which can be some distance from where it was injected. More is in filler migration.

Ultrasound first: what the scan shows in the folds

Dr Sin Yong scans the folds himself with high-frequency ultrasound before any treatment. The scan shows what a lump or a fullness is likely made of, how deep it sits and how far it spreads, because different fillers tend to look different on the scan (Wortsman 2015). It also shows the blood vessels: the facial artery and its branches run close to the smile line, so the scan guides where the needle goes.

The scan also helps show when fullness is not product at all but swelling, fluid or your own tissue. In the ultrasound study above, scanning with Doppler helped avoid unnecessary treatment (Gonzalez 2024). Under ultrasound guidance, hyaluronidase can be placed directly into the filler deposit (Schelke 2018).

Which product is in your folds, and what can be done

The product decides what can be dissolved and what cannot, so the scan and your history come before any plan.

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Hyaluronic acid: dissolved in stages

Hyaluronidase is an enzyme that acts on hyaluronic acid only. Earlier hyaluronidase and any bee or wasp sting allergy are asked about. Before planned dissolving, Dr Sin Yong always does a skin test: a small amount of hyaluronidase is injected just under the skin to check for a reaction. A small first dose is then placed into the mapped filler and the area is reviewed at about 48 hours, with any further dose aimed at what remains. Published guidance advises titrating the dose to effect and testing before planned dissolving, but not where a delay could cause harm in an emergency (King 2018). Dissolving more than the excess can leave a hollow, which is why the enzyme is aimed at the excess and given in stages. Dissolving does not lift tissue that has come down: once the excess is gone, the fold that is left is assessed for what is causing it. Refilling, if it is wanted at all, waits at least two weeks after hyaluronidase. The enzyme is explained in full in hyaluronidase: what it dissolves and its side effects.

Everything else: the Sculpting mode, without an incision

Being told a filler cannot be dissolved does not mean it has to be cut out. Dr Sin Yong maps collagen stimulators, silicone and other non-absorbable fillers with ultrasound and treats them with the Sculpting mode of Time Freeze Laser LCLR®, for nodules large and small, without an incision. Where hyaluronic acid sits with other products, as it often does after years of top-ups, the hyaluronic acid is dissolved first and the Sculpting mode is used for what remains. The laser has its own risks, including blistering or a change in skin colour, so settings are chosen for your skin. More is in the Sculpting mode of Time Freeze Laser LCLR®.

Surgery or treatment without an incision: what each involves

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The published evidence shows why taking filler out is harder than it sounds. In 98 patients treated for complications of polyacrylamide gel in the face and breast, the gel was removed through incisions, by squeezing and by rinsing; it could not be fully removed in 8, and it came back in 3 after apparently complete removal (Manafi 2010). Foreign-body granulomas grow finger-like into the tissue around them, which is why a treatment review puts surgical excision last (Lemperle and Gauthier-Hazan 2009).

Get assessed before you agree to surgery: an operation can still be done later if it is ever needed, but it cannot be undone.

Why more filler on top is not the answer

When a fold looks heavy or lumpy, the reflex is often to add filler around it to even things out. That adds weight to a lower face that is already carrying too much, hides a lump instead of dealing with it, and layers new product over old, which makes the next scan and the next treatment harder. On MRI, hyaluronic acid filler has measured larger than the volume injected, so each top-up adds to what is already there (Issa 2026). More injections can also set off a late reaction: with non-absorbable fillers, further filler injections were among the triggers of delayed problems (Kadouch 2013).

Dr Sin Yong does not add product to hide a problem. The excess and the lumps are dealt with first; whether anything is added back is decided only after the face has settled, and sometimes the answer is nothing. Where the whole face has become puffy, see pillow face; for the fold itself, see nasolabial folds.

Warning signs after smile line filler: when to act straight away

The facial artery and its branches run close to the smile lines, so a blocked blood vessel is a recognised risk of filler here. Watch the skin beside the nose and on the upper lip in particular.

Urgent: a change in vision or eye pain after filler: call 995 now. Skin that turns pale, dusky or mottled, or pain that is getting worse, needs urgent assessment by the doctor who injected you, or at A&E, now. See the warning signs of a blocked blood vessel after filler.

A lump that is red, hot, tender, draining or growing quickly may be inflammation or infection, and it is treated medically first. Consensus recommendations advise hyaluronidase for non-inflammatory reactions without active infection; an infection needs drainage, a sample for testing and medical treatment, not hyaluronidase as the first step (Baranska-Rybak 2024). Fever, or feeling unwell with a swollen lump, needs prompt review.

Tried other treatments and almost given up?

Many patients who come to see Dr Sin Yong about smile line and marionette line filler problems tell him they have tried almost everything else and had given up hope. Having tried other treatments does not mean nothing more can be done: what is done next depends on what the scan shows.

That history is useful. Knowing what was injected, when, and what has already been tried often explains why a problem has stayed: hyaluronidase acts only on hyaluronic acid and only where it reaches, some fillers are not hyaluronic acid at all, and swelling or fluid can look like filler. Ultrasound helps show which of these applies, and the plan starts from there. For material that cannot be dissolved, Dr Sin Yong uses the Sculpting mode of Time Freeze Laser LCLR® for nodules large and small, without an incision. How each person responds varies.

If you have been told nothing more can be done, it is still worth having the area scanned: ultrasound helps show what is there, and the plan is made from that. Bring any records of past treatments, product names and dates if you have them. More on this is in when filler dissolving has not worked.

How Dr Sin Yong treats smile line filler problems without surgery

Dr Sin Yong developed the Time Freeze Laser LCLR® protocol himself and performs every scan, every dissolving and every Sculpting mode treatment himself on Orchard Road. He has been invited to share his clinical expertise in Seoul, Dubai, Bangkok and São Paulo, including as a Global Key Opinion Leader.

Bring what you know: the products, the dates and the clinics, and photographs from before the filler if you have them. Having no records is fine; the scan shows what is there. Filler placed elsewhere in Singapore or overseas is assessed in the same way; see filler done overseas.